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Doctors are experiencing a shift in the kinds of COVID patients they're seeing as Omicron spreads at unprecedented rates -- and it's not just more of them. Rather than patients with classic COVID pneumonia symptoms, they are treating more vaccinated patients with other conditions whose COVID infections have pushed them over the edge into more serious health crises.

"We have tons of people with COVID in the hospital, equal in number to what we had last winter, but very different patterns," said Christopher Cannon, MD, a cardiologist at Brigham and Women's Hospital and Harvard Medical School in Boston. "Amongst the vaccinated patients, it's more the COVID 'tip' type of thing. It's tipping over patients' other conditions to become worse."

Rather than primarily people with lung problems and ventilators, patients now present with issues that have something to do with COVID and something to do with heart failure or heart disease, for example, said Cannon. He is one of several interviewed doctors theorizing that fewer people with existing health problems sought medical care during last winter's COVID-19 peak -- perhaps fearing that they would catch the virus in the hospital -- and the lack of care is now catching up with them.

Cardiologist Biykem Bozkurt, MD, PhD, of Baylor College of Medicine in Houston, suggested that the combination of delayed-but-needed care accumulating over the years, short staffing, and a rise in vulnerable individuals worsening due to Omicron, has started to add up.

"It's creating a perfect storm in the healthcare system," said Bozkurt.

The situation illustrates a growing challenge with monitoring and communication about the virus.

Laypeople and clinicians have engaged in a "with" versus "for" debate that pits COVID-19 as a primary diagnosis against COVID-19 as a secondary or tertiary diagnosis.

Cardiologist Jim Januzzi, MD, of Massachusetts General Hospital and Harvard Medical School, calls this a false dichotomy. Both the patient with only COVID and a patient with another problem who happens to test positive for COVID may exist. But there's much in between. Someone that comes to the hospital -- "with COVID" and not "for COVID" -- may already be affected by the virus. It could have caused the problem they showed up with in the first place.

For example, he said, if someone comes into the hospital with a broken hip, and ends up testing positive for COVID, saying they had incidental COVID isn't useful. "If they hadn't gotten the coronavirus infection, they wouldn't have been weakened, they wouldn't have fallen and broken their hip," he said. "And that's the distraction that we as physicians and nurses, nurse practitioners, and others that see these patients would really desire people to stop getting confused about."

Still, doctors say, more research is needed to know what proportion of patients are hospitalized because COVID complicated their primary diagnosis. And then there's another possibility altogether: that the virus itself or any other number of .

"It's going to be impossible to deconvolute whether this is merely because they were tenuous to start with, and then got a serious respiratory illness that tipped them over the edge, or whether there's a specific cardiotropic aspect to the coronavirus," said Januzzi.

"We have numerous discussions at the hospital leadership level in regards to this question of the chicken-egg story," Bozkurt said. But for now, it's difficult for doctors to simply dismiss the role COVID plays in patients with other health problems, she said. "It's going to require a little bit more of a refinement in science and research for us to immediately say, 'Well, you know, these people just serendipitously happen to be found to have COVID,'" versus a condition worsened by COVID, or COVID as a primary reason for admission.

Omicron has been characterized as milder by some research, but even with so many people vaccinated, a smaller proportion of a much larger infected cohort is still more than hospitals can sustain. Meanwhile, the unvaccinated continue to present with serious pneumonia-like symptoms that are typically associated with COVID-19: shortness of breath, low blood oxygen, and fever.

Januzzi said that until the Omicron surge dies down, arguing about how a patient's condition is categorized is beside the point. "Ultimately, whether it's with COVID or for COVID, the message should be the same, which is to get vaccinated, wear masks, practice careful behavior until this wave relents."

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